This letter authorises the extended use of the following guidance until 1st December 2018:

NHS Grampian Westholme Woodend Hospital Queens Road ABERDEEN AB15 6LS NHS Grampian Date 29m May 2018 Our Ref FAJIVOST /MGPG/May 18 Enquiries to Frances Adamson Extension 56689 Direct Line 01224 556689 Email f.adamson(@nhs.net Dear Colleague This letter authorises the extended use of the following guidance until 1st December 2018: NHS Grampian Staff Guidance On Indications Antibiotic Switch Therapy (IVOST) In Adults This guidance remains clinically accurate and relevant, and the review of this guidance will commence shortly. If you have any queries regarding this please do not hesitate to contact the Pharmacy and Medicines Directorate. Yours sincerely a ci Sandy Thomson Interim Chair of Medicines Guidelines and Policies Group

NHS...,e... Grampian NHS Grampian Staff Guidance On Indications For IV Antibiotic Therapy And IV To Oral Antibiotic Switch Therapy (IVOST) In Adults Lead Author/Coordinator: Gillian Macartney Fiona McDonald Specialist Pharmacists - Antibiotics Reviewer: Dr Alexander Mackenzie Chair of Antimicrobial Group Approver: Dr Caroline Hind Chair of Medicines Guidelines and Policies Group Signature: "a Act ' 2...,. Signature: Apa...sksaj,4 Signature: 1,1 r 1 / Ajeti C'ci,,71 Identifier: NHSG/Guid/AblVOST/ MGPG747 Review Date: July 2017 Approval Date: July 2015 UNCONTROLLED WHEN PRINTED Version 4 Executive Sign-Off This document has been endorsed by the Director of Pharmacy and Medicines Management Signature: H--- -_--s..4 r- ---

This policy is also available in large print and other formats and languages, upon request. Please call NHS Grampian Corporate Communications on Aberdeen (01224) 554400. This controlled document shall not be copied in part or whole without the express permission of the author or the author s representative. Title: Unique Identifier: NHS Grampian Staff Guidance on Indications for IV Antibiotics and IV to Oral Antibiotic Switch Therapy (IVOST) in Adults NHSG/Guid/AbIVOST/MGPG747 Replaces: NHSG/Guid/AbIVOST/MGPG591, Version 3 Lead Author/Coordinator: Specialist Antibiotic Pharmacists Subject (as per document registration categories): Key word(s): Policy, Protocol, Procedure or Process Document: Document application: Purpose/description: Group/Individual responsible for this document: Policy statement: Prescribing Policy Antibiotic, Antibiotics, Antimicrobial, Antimicrobials, Infection, Infections, IVOST, IV, intravenous, switch, oral Guidance (Antimicrobial Prescribing Guideline) NHS Grampian To promote the appropriate use of antibiotics for adults in terms of the route of administration and treatment duration. Specialist Antibiotic Pharmacists It is the responsibility of all staff to ensure that they are working to the most up-to-date and relevant policies, protocols and procedures. It is the responsibility of individual prescribers to ensure the management of infections in primary care patients is within the guidance laid down in this document. By doing so, the quality of the services offered will be maintained, and the chances of staff making erroneous decisions which may affect patient, staff or visitor safety and comfort will be reduced. UNCONTROLLED WHEN PRINTED Review Date: July 2017 Identifier: NHSG/Guid/AbIVOST/MGPG747 - i -

Responsibilities for ensuring registration of this document on the NHS Grampian Information/Document Silo: Physical location of the original of this document: Job title of creator of this document: Job/group title of those who have control over this document: Development Pharmacist Medicines Management Pharmacy and Medicines Directorate, Westholme Specialist Antibiotic Pharmacists Specialist Antibiotic Pharmacists Responsibilities for disseminating document as per distribution list: Lead Author/Co-ordinator: Specialist Antibiotic Pharmacists Responsibilities for implementation: Organisational: Operational Management Team and Chief Executive Sector General Managers, Medical Leads and Nursing Leads Departmental: Clinical Leads Area: Line Manager Review frequency and date of next review: Every two years (or sooner if required) Responsibilities for review of this document: Lead Author/Co-ordinator: Specialist Antibiotic Pharmacists Revision History: Revision Date Previous Revision Date Summary of Changes (Descriptive summary of the changes made) June 2015 June 2013 Update of oral bioavailability tables and references Changes Marked* (Identify page numbers and section heading) p6 and 7 * Changes marked should detail the section(s) of the document that have been amended, i.e. page number and section heading. UNCONTROLLED WHEN PRINTED Review Date: July 2017 Identifier: NHSG/Guid/AbIVOST/MGPG747 - ii -

NHS Grampian Staff Guidance on Indications for IV Antibiotics and IV to Oral Antibiotic Switch Therapy (IVOST) in Adults Contents Page No Purpose... 2 Scope... 2 Background... 2 Key Practice Points For Hospital Prescribers... 2 Route of administration... 2 Antibiotic Choice... 2 Duration of antibiotic treatment... 2 Recording of information... 2 Benefits Of Early Switch... 3 Consideration Of Switch From IV To Oral... 3 Consideration For Outpatient Parenteral Antibiotic Therapy (OPAT)... 4 References... 5 Consultation List... 5 Comments received from:... 5 Appendix 1: SUGGESTED IVOST CHANGES... 6 Appendix 2: Summary Intravenous Antibiotic Oral Switch Therapy (IVOST) Protocol (Adults)... 7 UNCONTROLLED WHEN PRINTED Review Date: July 2017 Identifier: NHSG/Guid/AbIVOST/MGPG747-1 -

NHS Grampian Staff Guidance on Indications for IV Antibiotics and IV to Oral Antibiotic Switch Therapy (IVOST) in Adults Purpose To promote the appropriate use of antibiotics for adults in terms of route of administration and duration of treatment. Scope All hospital prescribers across NHS Grampian, plus all hospital nursing and hospital pharmacy staff. Background Antibiotics are amongst the most commonly used drugs in hospital. On average, one third of patients receive antibiotic therapy, and approximately 40% of these patients will receive an intravenous (IV) agent¹. Up to 40% of antibiotic prescriptions are incorrectly prescribed or inappropriate, which often reflects overuse of expensive IV antibiotics¹. Antibiotics should be prescribed only for suspected or confirmed bacterial infection and where there is likely to be clear, clinical benefit. Inappropriate use of the intravenous route can have adverse consequences for patients, future antibiotic resistance patterns, staff time and financial resources. Prudent antibiotic prescribing, which includes the appropriate route of administration and length of treatment, will help to avoid these consequences and ensure optimal patient care and use of resources. Key Practice Points For Hospital Prescribers Route of administration The intravenous route should be used if the patient: Has a severe infection, systemic inflammatory response and/or is unstable clinically Requires high doses which cannot be delivered via equivalent oral preparation Is likely to have an absorption problem or is nil-by-mouth. Antibiotic Choice Broad-spectrum antibiotics may be appropriate initially when the infecting microorganism is unknown but this should be changed to a narrower spectrum antibiotic once culture results are available. Duration of antibiotic treatment This depends on a number of factors other than the suspected micro-organism: Site of infection Immune status of patient Presence/removal of prosthetic material Speed of treatment with effective antibiotic(s) Supportive therapy Surgical intervention as required Clinical response. Recording of information In order to ensure good practice, medical staff must record the following information in the patient s medical notes within 24 hours of starting all antimicrobials: Indication (diagnosis, site of infection) UNCONTROLLED WHEN PRINTED Review Date: July 2017 Identifier: NHSG/Guid/AbIVOST/MGPG747-2 -

Assessment of severity temperature, pulse rate, blood pressure, respiratory rate, white cell count and C-reactive protein (if available) Type of microbiology specimens collected prior to antimicrobial administration Details of relevant microbiology results Antimicrobial(s) prescribed: name, route, dose and stop/review date or course length. Benefits Of Early Switch There are a number of advantages to support the prompt switch from IV to oral therapy, these are as follows; Reduction in the likelihood of hospital acquired bacteraemia and infected/phlebitic IV lines. Patient is more likely to receive oral antibiotics at the correct time and miss fewer doses. Potential reduction in the risk of adverse reactions; errors in preparation are significantly higher with parenteral drugs, compared to oral formulations. Reduces patient discomfort and enables improved mobility and the possibility of earlier discharge from the hospital. Saves medical and nursing time. Potential reduction in treatment costs allowing finances to be more appropriately allocated. Consideration Of Switch From IV To Oral N.B. IV to oral switch therapy is NOT appropriate in critically ill patients who require IV antimicrobials or in patients unable to absorb drugs after oral administration. Indications to continue IV therapy: Oral route compromised o vomiting, nil by mouth, severe diarrhoea, steatorrhoea, swallowing disorder, unconscious. Continuing sepsis o 2 or more of the following: temp > 38 C or < 36 C, heart rate > 90bpm, respiratory rate > 20 breaths/minute, WCC > 12 or < 4 Special Indication requiring high dose IV therapy o e.g. endocarditis, meningitis, Staph aureus bacteraemia, immunosuppression, bone/joint infection, deep abscess, cystic fibrosis, prosthetic infection. Febrile with neutropenia Hypotension/shock o A low blood pressure is associated with reduced blood flow to the gut and reduced / unpredictable drug absorption. For skin and soft tissue infections o IV therapy indicated if there is heat, erythema and induration or sepsis syndrome. If none of the above indications for IV therapy applies and the signs/symptoms of infection are improving, then the patient would be eligible for a switch to oral antibiotics. UNCONTROLLED WHEN PRINTED Review Date: July 2017 Identifier: NHSG/Guid/AbIVOST/MGPG747-3 -

Use narrow spectrum antibiotics or stop antibiotic therapy where possible and appropriate. If no suitable oral formulation of the drug is available, contact microbiology or ward clinical pharmacist for advice. See Appendices 1 and 2 for oral switch options and summary of indications for continued IV therapy. When a patient has an enteral tube (e.g. N/G or PEG) in place that allows medication to be administered reliably, a switch to an appropriate oral formulation of the antibiotic administered via the tube, may be considered provided that gastric motility has been established. Care must be taken when administering antibiotics via the enteral tube due to the potential for interactions with feeds, e.g. ciprofloxacin, flucloxacillin. For further information on any aspect of drug administration via an enteral tube, contact Medicines Information (Tel 52316) or ward Clinical Pharmacist. Consideration For Outpatient Parenteral Antibiotic Therapy (OPAT) Some patients may be suitable for consideration for OPAT if they are not suitable for oral switch but are clinically stable and their only requirement to be in hospital is to receive antibiotics. Patients may need their antibiotic regime rationalised for outpatient treatment to minimise frequency of administration and simplify regime. Some suitable infections include: Bone/Joint infections Vascular graft infections S.aureus bacteraemia Wound infections Endocarditis Discitis Lyme disease. OPAT Patient selection criteria includes: IV therapy is necessary condition stable and well enough to be treated out of hospital no other medical problems requiring inpatient care patient willingness to participate in OPAT physically/mentally able to attend clinics no drugs/alcohol/self harm history family /other support telephone access for emergencies. If a patient is considered to be a potential candidate then please refer to Sharon Falconer, OPAT Specialist Nurse (bleep 3526). Further information is available on the intranet http://intranet.grampian.scot.nhs.uk/ccc_nhsg/12539.html UNCONTROLLED WHEN PRINTED Review Date: July 2017 Identifier: NHSG/Guid/AbIVOST/MGPG747-4 -

References 1. McLaughlin et al. Pharmacy-implemented guidelines on switching from intravenous to oral antibiotics: an intervention study. Q J Med 2005; 98; pp745-752. 2. Gould et al. Managing Skin and Soft Tissue Infections: expert panel recommendations on key decision points. Journal of Antimicrobial Chemotherapy, 2003; 52; S1; i3- i17. 3. Summary of Product Characteristics for various antibiotic preparations [accessed via www.medicines.org.uk]. 4. Martindale (entries for various drugs) www.medicinescomplete.com 5. Sandford Guide to Antimicrobial Therapy 2013. 6. ADFS [accessed online via www.medicinescomplete.com]. 7. John Hopkins Antibiotic Guide via www.hopkinsguides.com 8. Kucer s The Use Of Antibiotics www.medicinescomplete.com Consultation List This document (including summary guide) was originally developed in consultation with: All Consultants Group Pharmacy HSCP Clinical Hospital Leads HSCP Pharmacists Medical Microbiology Registrars Non-Medical Prescribers Unit Nurse Managers Review consultation list (for 2015 update): All Acute Sector Pharmacists Comments received from: Janet Hasell, ICU Pharmacist, ARI Jennie Hewitt, Pharmacist, ARI Lisa Davidson, Pharmacist, ARI This policy has been reviewed and agreed by; NHS Grampian Antimicrobial Management Team July 2015 NHS Grampian Medicines and Guidelines Group July 2015 Distribution List All Consultants Group Pharmacy HSCP Clinical Hospital Leads HSCP Pharmacists Medical Microbiology Registrars Non-Medical Prescribers Unit Nurse Managers UNCONTROLLED WHEN PRINTED Review Date: July 2017 Identifier: NHSG/Guid/AbIVOST/MGPG747-5 -

Appendix 1: SUGGESTED IVOST CHANGES Always check for allergy, interactions and antibiotic sensitivity profile for any positive microbiology results See Acute Sector Empirical Guidance for specific oral switch options for various conditions. For IV antibiotics with no oral formulations the switch should be guided by specialist advice or as per microbiology sensitivities. IV antibiotic Oral option Oral Bioavailability (Adjust dose according to renal and hepatic function) (** reduced by food) Amoxicillin Amoxicillin 500mg-1g, 8hourly 74-92% Benzylpenicillin Ciprofloxacin Amoxicillin 500mg-1g, 8hourly or phenoxymethylpenicillin (Penicillin V) 500mg-1g, 6 hourly only for Streptococcal throat infections Ciprofloxacin 500-750mg, 12 hourly (higher dose if Pseudomonas spp. isolated) 60% ** (phenoxymethylpenicillin) 70-80% Clarithromycin Clarithromycin 500mg, 12 hourly 50-55% Clindamycin Clindamycin 300-450mg, 6-8 hourly. 90% Maximum dose 600mg, 8 hourly in severe infection (or 450mg, 6hourly) Co-amoxiclav Narrow spectrum where possible, e.g. 70-99% amoxicillin Co-amoxiclav 625mg, 8 hourly Co-trimoxazole Co-trimoxazole same dose 85-100% Flucloxacillin Flucloxacillin 500mg-2g, 6hourly 80%** [doses above 2g daily unlicensed] Fluconazole Fluconazole same dose >90% Gentamicin Seek specialist advice or as per NA microbiology sensitivities. Consider if gram negative cover still required. Levofloxacin Levofloxacin same dose but doxycycline or 98-100% co-trimoxazole may be a more appropriate oral option (less risk of C. difficile) Linezolid Linezolid same dose 100% Metronidazole Metronidazole 400mg, 8 hourly >90% Piperacillin/tazobactam Seek specialist advice or as per NA microbiology sensitivities Rifampicin Rifampicin same dose 70-95% ** Teicoplanin Seek specialist advice or as per NA microbiology sensitivities Vancomycin Seek specialist advice or as per microbiology sensitivities NB: oral vancomycin not suitable for systemic infection (only indicated for Clostridium difficile Infection) NA UNCONTROLLED WHEN PRINTED Review Date: July 2017 Identifier: NHSG/Guid/AbIVOST/MGPG747-6 -

Appendix 2: Summary Intravenous Antibiotic Oral Switch Therapy (IVOST) Protocol (Adults) Review the need to continue IV antibiotic DAILY Oral route compromised (vomiting, nil by mouth, severe diarrhoea, steatorrhoea, swallowing disorder, unconscious) Continuing Sepsis (2 or more of the following: temp > 38 C or < 36 C, heart rate > 90bpm, respiratory rate > 20 breaths/minute, WCC > 12 or < 4) Special Indication (Including endocarditis, meningitis, Staph.aureus bacteraemia, immunosuppression, bone/joint infection, deep abscess, cystic fibrosis, prosthetic infection) For Skin or Soft Tissue Infections please refer to main IVOST guidance. Febrile neutropenia Hypotension/shock If yes to any of the above Continue IV antibiotics and review again after 12 24 hours (where appropriate) If no to all of the above Make appropriate oral switch Monitor patient response after switch IV antibiotic Oral option (Adjust dose according to renal and hepatic function) Oral Bioavailability (**reduced by food) Amoxicillin Amoxicillin 500mg-1g, 8 hourly 74-92% Benzylpenicillin Amoxicillin 500mg-1g, 8 hourly or phenoxymethylpenicillin 500mg- 1g, 6 hourly only for Streptococcal throat infections 60% ** (phenoxymethylpenicillin) Ciprofloxacin Ciprofloxacin 500-750mg, 12 hourly 70-80% (higher dose if Pseudomonas spp. isolated) Clarithromycin Clarithromycin 500mg, 12 hourly 50-55% Clindamycin 300-450mg, 6-8 hourly. 90% Maximum dose 600mg, 8 hourly or 450mg, 6 hourly in severe infection Co-amoxiclav Narrow spectrum where possible e.g. amoxicillin Co-amoxiclav 625mg, 8 hourly 70-99% Co-trimoxazole Co-trimoxazole same dose 85-100% Flucloxacillin Flucloxacillin 500mg-2g, 6hourly 80% ** [doses above 2g daily unlicensed] Fluconazole Fluconazole same dose >90% Gentamicin Seek specialist advice or as per microbiology sensitivities. NA Consider if gram negative cover still required. Levofloxacin Levofloxacin same dose but doxycycline or co-trimoxazole 98-100% may be more appropriate oral options (less risk of C diff) Linezolid Linezolid same dose 100% Metronidazole Metronidazole 400mg, 8 hourly >90% Piperacillin/tazobactam Seek specialist advice or as per microbiology sensitivities NA Rifampicin Rifampicin same dose 70-90% ** Teicoplanin Seek specialist advice or as per microbiology sensitivities NA Vancomycin Seek specialist advice or as per microbiology sensitivities. NB: oral vancomycin not suitable for systemic infection (only indicated for Clostridium difficile Infection) NA For IV antibiotics with no oral formulations the switch should be guided by specialist advice or as per microbiology sensitivities. UNCONTROLLED WHEN PRINTED Review Date: July 2017 Identifier: NHSG/Guid/AbIVOST/MGPG747-7 -